Trauma Centers Short of Patients As New York's Crime Rate Drops

New York City's historic drop in violent crime may be good for New Yorkers, but it is proving troublesome for a costly, prestigious and highly competitive enterprise: treating victims of shootings, stabbings and other trauma.

Through the late 1980's and early 1990's, a steady stream of mugging, knifing and gunshot victims flowed into the city's hospitals, supplying much of the material for what became a $250-million-a-year business. City and state officials approved the creation of 17 ''level one'' trauma centers -- costly, up-to-date units that keep teams of elite surgeons and nurses on call to treat the most severe injuries.

But as the system grew, critics contended that New York's glut of hospitals and the medical industry's fierce territorialism were leading to the creation of too many centers. Now, critics say the drop in crime may place some of the trauma centers in jeopardy.

An analysis by The New York Times has found that the number of trauma victims -- typically victims of accidental falls, car accidents and gunfire -- dropped 20 percent citywide between 1993 and 1996. Although the number of car crash and fall victims remained roughly the same, the number of gunshot wound victims plummeted more than 50 percent.

Trauma surgeons say some centers that once handled a constant stream of life-and-death emergencies are now underworked. And aside from the cost of running the expensive units, some experts say, the shortage of patients could actually be compromising the level of care.

With too few patients, trauma surgeons who must execute complex, life-saving maneuvers at high speed are unable to keep their skills honed, said Dr. Marcel Martin, the outgoing director of Staten Island University Hospital's trauma center.

The lack of trauma patients, he said, forced him to use more cadavers to educate medical students. ''This is totally stupid,'' Dr. Martin said. ''I've never seen anything like it in my life.''

The Times analysis also found that some of the city's least-busy trauma centers appear to be handling fewer than the minimum number of severely injured patients required by the state health code to maintain their designation.

The city's busiest trauma center, at Kings County Medical Center in Brooklyn, saw 1,600 cases in 1996, or roughly 4 a day, according to hospital figures. That was down almost 40 percent from the 2,600 cases in 1991. The number of patients at the trauma center of Lincoln Hospital, in the Bronx, dropped to 1,500 in 1996 from roughly 2,300 in 1993.

In Los Angeles and Chicago, by contrast, the majority of trauma patients are treated at a single workhorse center in each city. The Los Angeles County Medical Center handles more than 7,000 trauma cases a year, or more than 19 a day; Cook County Hospital in Chicago handles roughly 5,000 cases a year, or about 13 a day.

Experts say the original goal behind the introduction of trauma centers -- concentrating high-quality trauma specialists in a handful of regional facilities -- is being compromised in New York.

''You have too many pretenders in the system and it dilutes patient care,'' said Dr. David R. Boyd, who served as the Federal Government's Director for Emergency Medical Services from 1974 to 1982 and invented the trauma system concept. ''They're wasting money and they're misrepresenting trauma care to the community.''

But Dr. Arthur Cooper, a trauma surgeon at Harlem Hospital and vice chairman of the State Department of Health's Trauma Advisory Committee, said that although some studies showed that busier trauma centers performed better, others showed that being too busy can reduce the quality of care.

But what the minimum number of patients should be is the subject of debate. The Department of Health is currently not enforcing the minimum-volume standards it established in 1990, state officials said. The department, which was a world leader in showing that increased volume improved cardiac surgery care, is now using a trauma database it created in 1994 to study how volume affects trauma care.

''We're aware that a few hospitals in New York City and upstate are not making the minimum,'' said Frances Tarleton, a spokeswoman for the State Department of Health. ''But we're not sure whether that has a negative impact on care or not.''

State Won't Disclose Trauma Center Figures

Ms. Tarleton said that the state trauma database figures are private and that the state would not disclose which city trauma centers are not making the 1990 state minimum. But the Times analysis, based on publicly available admissions records, showed that the least busy trauma centers in the city are New York Hospital Queens, Harlem Hospital, St. Luke's Roosevelt Hospital and St. Vincent's Medical Center of Richmond. Officials at those hospitals disputed The Times's figures or said the quality of care in their trauma centers was comparable to that of busier centers.

Dr. Rodger W. Yurt, a trauma surgeon at New York Cornell Medical Center and chairman of the city's Trauma Advisory Committee, said that New York's congested streets and high-rises -- which render helicopters impractical -- make it prudent to have more trauma centers per capita than elsewhere.

The 17 centers in the 5 boroughs serve a population of roughly 7.2 million; by comparison, 6 level-one centers serve the 9.1 million people in Los Angeles County.

New York's situation is not unique. A nationwide drop in the number of trauma patients -- at least partly fueled by increased use of air bags and seat belts -- is sparking debate in other cities, said Dr. David B. Hoyt, Director of Trauma at the University of San Diego Medical Center and chairman of the American College of Surgeons' Committee on Trauma.

Studies show that severely injured patients are more likely to survive if they reach a trauma center than if they are taken to a standard emergency room. But the resources required to open one are considerable.

Each trauma center must have a surgeon with at least five years of experience on duty at all times. A dozen specialized surgeons must also be on call, able to arrive within 30 minutes. And millions of dollars' worth of high-tech equipment must be available.

In an age of increasing competition and managed care, the stakes for hospitals are high. While expensive to operate, trauma centers can make money if they attract the right mix of patients. Even with the drop in trauma patients, New York hospitals billed more than $225 million for trauma care in 1996, according to the Times analysis.

The prestigious centers also help hospitals to attract top doctors and medical students and, equally important, patients who believe that the hospitals must be exceptional if they have trauma centers.

Dr. Harold Osborne, chairman of the city's Advisory Committee on Emergency Medicine and director of the emergency department at Lincoln Medical Center in the Bronx from 1993 to 1997, said that marketing and ego too often play a role in hospitals' opening trauma centers.

''It's a question of cachet, reputation and status,'' he said. ''Hospitals in the era of managed care are hustling to be recognized for excelling in any area. You have politics overcoming health-care economics and rational health-care planning.''

Critics of New York's system say the clearest example of its excess is on Staten Island. Currently, if someone is critically injured in a car on an even-numbered day, paramedics will rush the person to St. Vincent's Hospital of Richmond. But if the accident is on an odd-numbered day, paramedics take the victim to Staten Island University Hospital.

The arrangement was approved by state and city health officials in the mid-1980's as part of a delicate compromise. Both hospitals desperately wanted level-one trauma centers. But there was a shortage of neurosurgeons and there were not enough serious trauma cases on Staten Island to justify two units.

Dr. James Coil, director of St. Vincent's Hospital of Richmond's trauma center, said the arrangement cut costs without decreasing the quality of care.

But Dr. Martin, the outgoing director of Staten Island University's trauma center, and trauma experts in other cities called the arrangement wasteful and potentially damaging to the quality of care.

Critics say the city's Trauma Center Advisory Committee, which consists of local trauma surgeons; the city Emergency Medical Service, and the State Department of Health have approved the creation of too many centers. They say that an outside agency, like the American College of Surgeons, should be involved.

Originally established as 10 trauma centers in 1984, the system grew to 15 by 1990. And over the past 18 months, two new pediatric level-one trauma centers were approved. Of the city's 17 centers, 10 are in private hospitals, including the 7 created since 1984.

But Dr. Alexander Kuehl, who established the city's trauma system as medical director of the Emergency Medical Service from 1981 to 1989, defended the current committee and New York's system. He pointed out that hospitals in other cities withdrew from trauma care when it became unprofitable for them.

''I truly am grateful that the hospitals have kept the resources there,'' he said.

Whether that will remain true remains to be seen. Trauma surgeons at several of New York's busiest centers said that patient volume is dropping or has reached a plateau. The change at Kings County has been the starkest. During the early 1990's, the hospital earned the grim distinction of having one of the country's busiest and best trauma centers for gunshot wounds.

''They used to say we saw more than most men who went through Vietnam,'' Dr. Lisa Patterson, the director of Kings County's trauma center, said somewhat wistfully. ''I was on call this New Year's Eve and we had one case after midnight. That's it.''

Top-Quality Care, But a Flawed System

Reflecting the opinion of most of the New York trauma surgeons interviewed, Dr. Patterson said the city's system provided top-quality care. But she agreed that there were flaws, asserting that too many trauma centers are in Manhattan and on Staten Island. Manhattan, with 1.5 million people, has 6 trauma centers, while Brooklyn, with 2.1 million people, has only 2 -- the same as Staten Island, which has only 395,000 people. As a result, many trauma patients from southern Brooklyn are transported to Staten Island for treatment.

Critics say that one of Staten Island's trauma centers should be eliminated. Meanwhile, Lutheran Hospital in southern Brooklyn plans to apply to open a trauma center, hospital officials said.

Some experts believe that economics may thin the ranks, even if regulators do not. In Miami, the high cost of trauma care led to the consolidation of six trauma centers in the late 1980's to one mammoth center. Chicago and Los Angeles also saw the number of trauma centers drop in the early 1990's.

Already, the drop in gunshot patients in New York is leading some hospitals that traditionally treated many such victims to encourage more distant ambulance services to bring them trauma patients.

Dr. Ronald Simon, director of trauma surgery at Jacobi Medical Center in the northeast Bronx, said his hospital is now welcoming patients from lower Westchester County. Trauma experts pointed out that Westchester trauma patients, many of them people with medical insurance who are in car accidents, can be more profitable than gunshot victims, who often have no insurance.

Dr. Simon predicted that increased competition would inevitably lead to fewer hospitals and fewer trauma centers. ''I think with the changes in health care, some hospitals are going to survive and some aren't,'' he said. ''In order to survive, you have to hustle.''

But Dr. Unsup Kim, director of Elmhurst Hospital's trauma center, predicted that the system would remain essentially unchanged, given the city's concentration of prestigious medical schools and powerful hospitals, and the politics of the health-care industry.

''All the trauma centers have affiliations with large institutions,'' he said. ''I don't see it happening in New York.''

Graph: ''AT A GLANCE: Too Many Centers, Not Enough Trauma''

The decline in the city's violent crime rate has caused the 17 trauma centers shown on map of New York City to become underused. Graph tracks volent crime rate for each 100,000 residents, from 1993 through 1996. It also tracks the number of trauma patients citywide, over the same period. (Source: Analysis of F.B.I. dataNot Enough Trauma)(pg. B7)